Role of the Simultaneous Sequential Strategy for Failed Acute Sinus Restoration after Modified Left Maze Procedure for Persistent Atrial Fibrillation with Concomitant Mitral Surgery

Abstract

We assessed whether the simultaneous sequential strategy could (1) achieve additional sinus restoration for those patients who were not in sinus rhythm while coming off bypass after modified left maze procedure and (2) attain the same long-term success rates as the bi-atrial maze procedure in patients with persistent atrial fibrillation (AF) and mitral valve disease. Twenty-seven consecutive patients - ten men and 17 women with a mean age of 52 +/- 13 years, all with persistent AF and mitral valve disease - underwent the modified maze procedure with the simultaneous sequential strategy. In the first phase, the modified left atrial maze operation was carried out with concomitant valvular surgery; the right side maze operation was subsequently carried out as a second phase of the sequential strategy only if AF re-appeared following the spontaneous restoration of heart beats during the operation. Twenty patients (74.1%) underwent the left atrial maze procedure only, and seven patients (25.9%) required the subsequent right atrial maze procedure as part of the sequential strategy. At a mean follow-up of 15.1 +/- 7.7 months, six of the 27 patients (22.2%) who underwent additional right atrial maze procedure had restored sinus rhythm. At a mean follow-up of 17.8 +/- 7.3 months, 24 of the 27 patients (88.9%) had restored sinus rhythm and 22 patients (81.5%) had restored bi-atrial transport function (right atrial filling fraction: 40.8 +/- 11.7%; left atrial filling fraction: 22.9 +/- 8.1%) after application of the sequential strategy. Compared with modified left atrial maze procedure, the application of the simultaneous sequential strategy successfully restored sinus rhythm in an additional 22.2% of patients with persistent AF. The overall sinus conversion rate of 88.9% was comparable with that of the standard bi-atrial maze procedure.